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BOX 10
064NER' S NAME
PUTNAM COUNTY HEALTH DEPARTMENT
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
PROPOSAL FOR SEWAGE DISPOSAL SYSTEM REPAIR
PHONE 271°j -;'0 lI
SITE LOCATION / ,:�- o Ve -l-V -1, y Lc%A 7M#
MAILING ADDRESS Qo�Af UV �v� -r•e �•,., Ic,�t• �.,
PERSON INTERVIEWED Pall) Complaint $
Name & Relationship (i.e, owner,tenant, etc.) p
DATE T- 1 = G l UU TYPE FACILITY
PROPOSED INSTALLER �` S`�`� a� � • � ��c . PHONE
REGISTRATION # IU(
Proposal (include sketch locating all adjacent wells):
NOTE: Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal fran licensed professional engineer or
registered architect. _ _ —t I It n ► ► t k . k
's Siqnature & T
Proposal Disapproved
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Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name.
b. Site Street Name, Town and Tax Map number.
c. Location of installed components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam. x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be performed in accordance with the above proposal and conditions.
I, as owner, or rep agent of owner agree to the above conditions.
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